Medicare can provide coverage for substance abuse treatment. Sadly, many people suffer without treatment every year because they’re unaware of available options.
The condition of “substance abuse” is no longer used by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead, “substance abuse disorder” is the preferable verbiage. A person’s use of alcohol or drugs (prescription or recreational) impairing his or her capability to manage life could have a substance abuse disorder.
Responsibilities such as work, school and/or home or health causes, problems or disabilities are often difficult to manage for these individuals. Social impairment, impaired control, risky behaviors, impulsive behaviors, and other criteria are evidence of a proper diagnosis.
Medicare can help by providing coverage for beneficiaries who meet the requirements to qualify. The Centers for Medicare & Medicaid Services (CMS) offers a wide range of service options. Options include services and treatments for substance abuse disorders.
Medicare Coverage for Substance Abuse Treatment
Substance abuse treatment programs can help save and restore a person’s life. Medicare doesn’t have a specific benefit category for these programs, but they do cover the costs of services for those who are in need.
Medicare offers coverage for substance abuse treatment programs, providing it’s medically necessary for the patient. Programs must provide reasonable services that are specific to treating a person’s addiction and abuse disorder(s).
Medicare covers treatment service costs for both inpatient and outpatient settings.
Your health-care provider will suggest and document that treatment services are medically necessary for treating your condition. Beneficiaries have coverage when receiving treatment services from a facility that Medicare approves.
On the other hand, beneficiaries receiving treatment from non-approved Medicare providers will create an unnecessary medical expense. Meaning, you’re responsible for the cost of treatment if you receive services from a provider who doesn’t accept Medicare; potentially putting you in financial distress. Make sure your healthcare provider accepts Medicare before receiving any treatment.
Lastly, Medicare requires health-care professionals to set up a plan of care for their patient suffering from substance/alcohol abuse. These plans will help the patient see what’s in store for their treatment in the future.
Treating Substance Abuse
Medicare covers medically necessary drugs to treat substance abuse, whether given during a hospital stay or injected at the doctor’s office. While this may be true, Medicare will not provide coverage for methadone or similarly administered drugs to treat substance abuse.
However, Medicare will cover these drugs for other conditions like chronic pain, when given in an inpatient or hospital setting.
Services like psychotherapy, patient education discussing diagnosis and treatment, and post-hospitalization/treatment follow-up are part of the treatment process. Medicare will cover these services.
Treating substance abuse is done through various treatments. Behavioral therapy can help each person learn how to cope with cravings and avoid the use of substance abuse.
Detoxing is a vital part of the treatment process. With the assistance of a medical provider, detoxing helps in the potential symptoms many will face when withdrawing from substances.
Counseling with family, group sessions with other substance abusers, and individual therapy to help your specific mental needs (as no two people/circumstances are exactly alike).
One thing we must keep in the front of our minds when discussing substance abuse is that no two cases or situations are the same. Therefore, no one specific treatment is appropriate for every individual suffering from substance abuse, even if the substance is the same (such as alcohol).
For example, Krystle and Theresa are both receiving treatment for their addiction to alcohol. Krystle has a plan of care from her doctor, but it doesn’t match Theresa’s. They thought their treatment plan would be the same because they’re both being treated for alcohol abuse. However, Theresa has underlying mental health issues and needs a different plan to accommodate her situation.
Medicare Part A Coverage for Substance Abuse
Medicare Part A may cover the cost of the stay for an inpatient facility. Your doctor or healthcare provider must first write a recommendation for treatment and believes it to be medically necessary for your condition.
Beneficiaries are responsible for any Part A deductibles, copayments, or coinsurance amounts that may apply.
In addition, any medications you’re taking while receiving care in an inpatient setting for substance abuse treatment may be covered by your Medicare Part A plan.
The Partial Hospitalization Program (PHP) may also be by Medicare under substance abuse treatment. However, for Medicare to cover costs your doctor must certify that you need twenty hours or more of therapeutic services each week.
Your doctor or healthcare provider must submit a plan for treatment and recertify your medical needs for PHP care on a regular basis for Medicare to continue covering the cost.
Part B and Substance Abuse
Outpatient substance abuse counseling may fall under the Medicare Part B coverage plan, just like it covers counseling services for any other mental illness.
Medicare coverage includes the cost of counseling services under Part B. However, counseling must come from a mental health professional or other qualifying professional(s). Doctors include psychiatrists, clinical psychologists, nurse practitioner or PA (physician’s assistant) or a clinical social worker.
Once you meet your Medicare Part B deductible, Medicare may pay for 80% of allowable charges for counseling sessions. Medicare requires counseling sessions to be held in the provider’s office, a hospital outpatient setting, or a community mental health center. Medicare beneficiaries will be responsible for the remaining 20%.
Hospital-outpatient settings may require a copayment or coinsurance cost when receiving treatment in these facilities.
Part D and Substance Abuse
The Medicare Part D Prescription Drug Plan covers most prescription medications for substance abuse. Part A pays for the Medications you receive as part of an inpatient treatment program.
Medicare Part B provides coverage for some medications given by an outpatient facility for the treatment of substance abuse. Part B covers medications that are given to you by a healthcare professional, meaning they can’t be self-administered.
Medicare Part B coverage for outpatient prescription drugs specifically used to treat substance abuse and addiction requires different criteria. Ask your doctor or healthcare provider any questions concerning suggested treatment/medications and coverage.
Get Help Paying for Medicare Substance Abuse Treatment
Do you, or someone you love has problems with substance abuse? Treatment options may be available to you. Substance abuse is something that requires treatment and the faster, the better the results will be.
Call one of our licensed Medicare agents today at the number listed above or fill out a form online. We can answer any questions or concerns you may have, provide helpful information or resources. Our services are here for your needs, with zero cost to you!